As healthcare has become more complex there is a growing recognition that most quality problems are no longer the result of single issues or decisions, but due to the breakdown of complex pathways and processes. Traditional approaches to improving quality such as producing guidelines and promoting training are still necessary, but are not sufficient to deal with this complexity on their own. Thanks to evidence-based medicine, clinicians usually know what to do in given circumstances. Quality failures occur because they struggle to understand how to translate this evidence into practice, especially when best treatment involves multiple, linked interventions. In order to ensure that all the key steps in complex processes happen consistently for every patient every time, clinicians need to have an understanding of the science of quality improvement (QI) that draws on lessons from manufacturing, engineering and psychology.
The best known approach to QI in healthcare is the IHI Model for Improvement, which is based on the principle that the best solutions are developed and tested through repeated small tests of change carried out by front-line staff. This PDSA (Plan, Do, Study, Act) approach occurs within a framework of three fundamental questions:
- What are we trying to accomplish?
- How will we know that a change is an improvement?
- What changes can we make that will result in an improvement?
In the Model for Improvement the overall aim (’What are we trying to achieve?’) is set by the project leadership but local teams are encouraged to experiment with specific problems, testing and measuring different approaches in repeated PDSA cycles. This recognises that local context, culture and experience is very different in different settings, and that the people most likely to be able to recognise and address this are clinicians and others working at the front line through an iterative testing process. The end result is that while numerous teams are working towards the same aim, it is usually achieved it through a range of different approaches that have developed in the light of local context. Evidence from other industries is that changes, which have developed like this, are much more likely to be accepted by front-line staff and to be sustained than those imposed from above.
The IHI Model for Improvement (see figure) has been used extensively for local QI and has formed the basis of the Royal College of Physicians’ (RCP) successful initiative to embed QI in training curricula, the Learning to Make a Difference project. It has also been used in a number of national projects including Frailsafe, a checklist-based approach to ensure that frail older patients reliably receive evidence-based care on hospital admission. Frailsafe is led by the British Geriatrics Society, sponsored by The Health Foundation and supported by the RCP. The checklist covers six key interventions that are known to improve the quality of care of older patients (including medication review, cognitive assessment, removal of urinary catheters and falls risk assessment). The Model for Improvement has also been used in conjunction with national clinical audits of falls, lung cancer and inflammatory bowel disease where clinical teams have used data to support local QI. Other related QI methods (eg Lean, Six Sigma) have been used to a lesser extent in healthcare but have the same basic approaches as the Model for Improvement.
How can clinical leaders help to promote QI?
The most successful QI projects have committed and energetic clinical leadership but many others fail through insufficient clinical engagement. Success is more likely if improvement work is integrated into the overall operational activity of organisations and there is alignment of relevant incentives and penalties to support the aims.
While the technical skills for QI can be readily taught, successful QI also needs to be supported by a leadership culture that promotes an environment where front-line staff, especially clinicians, are encouraged and supported to experiment with different approaches and where they share learning with other teams working on similar problems. Clinical leaders have an important role in ensuring that key clinicians not only have the necessary time, training and infrastructure to get involved in QI but also in setting the organisational culture that promotes it.
Don Berwick, the international quality improvement expert who wrote a report for the NHS in response to the events at Mid Staffordshire, strongly promotes the concept of a ‘learning organisation’, which prioritises quality above all else, promotes absolute transparency and actively seeks and values feedback from patients and staff. In his words:
‘Culture change and continual improvement come from what leaders do, through their commitment, encouragement, compassion and modelling of appropriate behaviours’.
The RCP considers quality improvement to be a key aspect of work delivered by clinicians, in line with the GMC’s Good Medical Practice. A QI hub is currently being developed by the RCP to help clinicians develop skills and support them in completing projects successfully. In addition, the Learning to Make a Difference (LTMD) project, initiated by the RCP and Joint Royal College of Physicians Training Board (JRCPTB), aims to equip core medical trainees with QI skills, allowing them to take on QI projects during their 4–6 month rotations. The LTMD project provides resources both for trainees and their supervisors on how to set up and complete QI projects as well as monthly online support sessions.
References and resources
The IHI is an independent not-for-profit organisation based in Cambridge, Massachusetts, whose mission is to improve health and healthcare. Their work focuses on five key areas:
- Improvement capability
- Person and family-centred care
- Patient safety
- Quality, cost and value
- Triple aim for populations – using integrated approaches to improve care, population health and reduce costs.
The IHI produces professional development programmes tailored to all levels of the workforce, from executive teams to front-line staff. The IHI Open school supports free online learning on quality improvement to students, trainees and university faculty-based on the above key areas.
The Health Foundation (HF) is an independent UK-based charity that aims for a healthier UK population, supported by accessible, high-quality healthcare. The HF provides funding, fellowship and development opportunities to support interested healthcare professionals deliver quality improvement projects. Work funded by HF has been made available on their website providing insight into ongoing improvement work and giving ideas and inspiration.
With NHS Improvement, the Foundation also co-leads the Q initiative, which is a network of people with improvement expertise that aims to support its members in sustaining long-term improvement work.
As part of NHS Scotland, Healthcare Improvement Scotland encourages patients and staff to provide continuous improvement in healthcare practice. Its Improvement Hub (ihub) gives information on programmes of improvement work being delivered in Scotland, as well as toolkits on how best to carry out these programmes. The toolkits also signpost to methods and databases that can be used in evaluating the programmes.
The National Mortality Case Record Review (NMCRR) Programme is a collaborative project led by the Royal College of Physicians (RCP). It aims to help hospitals in England and Scotland standardise the way they review adult deaths in hospital and improve understanding about problems and processes in healthcare associated with mortality, and share best practice. A report on the pilot phase of the programme was published in 2017.
A promise to learn – a commitment to act (opens PDF, 359.43KB) report of the National Advisory Group on the Safety of Patients in England. (Berwick report). 2013.